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Rural-urban inequalities in health status and access to care are a significant issue in China, especially among older adults. However, the rural-urban differences in health outcomes, healthcare use, and expenditures among insured elders following China's comprehensive healthcare reforms in 2009 remain unclear. Using the Chinese Longitudinal Healthy Longevity Surveys data containing a sample of 2,624 urban and 6,297 rural residents aged 65 and older, we performed multivariable regression analyses to determine rural-urban differences in physical and psychological functions, self-reported access to care, and healthcare expenditures, after adjusting for individual socio-demographic characteristics and health conditions. Nonparametric tests were used to evaluate the changes in rural-urban differences between 2011 and 2014. Compared to rural residents, urban residents were more dependent on activities of daily living (ADLs) and instrumental ADLs. Urban residents reported better adequate access to care, higher adjusted total expenditures for inpatient, outpatient, and total care, and higher adjusted out-of-pocket spending for outpatient and total care. However, rural residents had higher adjusted self-payment ratios for total care. Rural-urban differences in health outcomes, adequate access to care, and self-payment ratio significantly narrowed, but rural-urban differences in healthcare expenditures significantly increased from 2011 to 2014. Our findings revealed that although health and healthcare access improved for both rural and urban older adults in China between 2011 and 2014, rural-urban differences showed mixed trends. These findings provide empirical support for China's implementation of integrated rural and urban public health insurance systems, and further suggest that inequalities in healthcare resource distribution and economic development between rural and urban areas should be addressed to further reduce the rural-urban differences.

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Objective Explore within and across nursing home (NH) racial disparities in end‐of‐life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships. Design Observational study merging, at the individual level, C2014‐2017 national‐level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used. Setting Long‐stay residents who died in a NH or a hospital within 8 days of discharge. Participants Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities. Main outcomes and measures The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH‐level proportion of black residents. Other covariates included socio‐demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility‐level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects. Results Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random‐effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities. Conclusions and relevance We found disparities between black and white residents with ADRD both within and across facilities. The within‐facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.